Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in condition that resulted in hospitalization. Specifically, a female resident with a history of kidney disease, diabetes, and high blood pressure experienced altered mental status and shortness of breath, leading to her transfer to the hospital. Documentation showed that the resident's emergency contact was not notified of the transfer, and the transfer form indicated that notification had not occurred. The family member only learned of the resident's hospitalization and unresponsive state from the hospital social worker, not from the facility. Interviews revealed that the LPN responsible for the transfer did not contact the resident's emergency contact, believing the resident was alert and able to notify her family herself. However, facility policy required that the resident's representative be notified of significant changes in condition and transfers, regardless of the resident's alertness. The interim DON confirmed that family notification should occur in all such cases. The failure to notify the family resulted in them being unaware of the resident's decline and subsequent hospitalization.